Thank participant for coming. Make sure travelling expenses have been dealt with. Collect the preassessment questionnaire and check if the participant had any problems filling it in.

Explain purpose of clinic visit and ask if participants have read the information pamphlet and if they have any questions about the study and the measures.

Explain we need to obtain their consent to be interviewed and measured today and to use information collected today and at previous times for research. Explain that even having given consent they can still decline to do any part of the interview or examination.

Explain that results of some tests (blood pressure, lung function and anthropometry) will be given to them today.

Explain we will be asking them to consent to send results to their GP that may be useful for their health care and that this will be explained at the relevant parts of the examination. Confirm the GP address already on the GP letter. If the GP details have changed use a new GP letter. If the participant does not want any results sent to their GP use the participant feedback letter rather than the GP letter.

Participant should now read and sign the general consent form. Delete any sections that the participant does not consent to (e.g. results to GP or use of blood sample for genetic aspects of health).

If the participant does not want results sent to GP, ask them to sign the clinical advisor consent form. Explain that if this consent is not given, a blood sample cannot be drawn and certain cardiovascular tests cannot be taken.

please give details in the table below. Use one row for each medication. Be sure to include use of puffer or inhaler or any medication for breathing, and any medications bought from a pharmacy.Use spare medication sheets if necessary and attach to questionaire

Has a doctor told you that you have any of the following health problems? Health Problem Other heart trouble (Valvular disease, Ischaemic heart disease, tachycardia, palpitations or heart murmur, other) Please specify

Echocardiographer to complete relevant part of the letter and sign the form. Please tick the box to confirm you have done this

1

Tick

E. SELF-COMPLETION

Introduce self-completion questionnaire

“Now it’s time for breakfast and while I am getting that ready I’d like to give you this questionnaire to fill in by yourself. The questions are about how you have been feeling recently. Please check with me if any of the questions are unclear.”

“We are collecting saliva to measure cortisol, one of the body’s hormones. Cortisol levels are related to many aspects of our health that we are measuring in this data collection. We would like you to unscrew the cap of this salivette tube and pop the swab in your mouth without touching it. We would like you to keep the swab in your mouth and roll it around your mouth for 1-2 minutes until you feel that you can longer prevent yourself from swallowing the saliva produced. Then we want you to spit the swab back into the small container and screw the top on.”

Now complete the saliva tracking form and hand both the form and saliva sample to the lab staff. Please tick to confirm you have done this.

1

Tick

“Cortisol levels can change between morning and night and we would like you to take some more saliva samples at home and post them back to the clinic. I’ll explain more about this at the end of the visit.”

K. ECONOMIC CIRCUMSTANCES

Introduce questions on economic circumstances:

“The next few questions are about your economic circumstances as this study and others show that things like income and your level of financial security can affect health in a number of ways.”

Which of the letters on the show card represents your total net household income? Please include our own and your partner’s earned income (after deduction for income tax and national insurance), any state benefits and any other sources of income such as pension and interest. Please also include contributions from other members of your household (such as children). Please choose the period (annual, monthly or weekly) that is most convenient for you to use. Then, find the amount in pounds which represents your net household income and state the corresponding letter. Letter

How frequently at home or at work do you use your hands in strong movements, such as squeezing water out of a towel, playing racket sports, digging the garden, or carrying heavy items such as a suitcase, briefcase, bucket or shopping bag?

Put your finger on this key marked ‘0’ and look at the screen. This is the only key you will need to use. Every time you see a ‘0’ or an ‘8’ on the screen press the key once as quickly as you can. We will start with a practice run to make sure you know what to do. Are you clear about it? I am going to start the machine now, so look for the ‘0’s or ‘8’s and press firmly as soon as you see one.

I’m now going to give you a slightly harder test. This time the numbers 1, 2, 3 or 4 will appear on the screen. I want you to press the key that has the same number as that on the screen. If you see a ‘4’ on the screen, press key 4 as quickly as possible. If you see a ‘1’, press key 1, and so on.

Use both hands to do this. Put the 1st and 2nd fingers of each hand on the four keys (1, 2, 3, 4). (Other fingers can be used if necessary.)

Now I want to see how well you remember a list of fifteen words. I will show you one word at a time and when I reach the end of the list you have one minute to write down as many words as you can. Please write the words in any order you like. It is best not to talk to anyone while you are doing this. Are you willing to do this test?

Nurse: Hand over the paper test booklet turn to page 3 and make sure the participant has a pencil. Show the words at two second intervals using Word List A or B as specified on contact sheet and on front page of booklet. Make sure the last word is shown for two seconds. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 5. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 7. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish.

Start at the top left and work along the row from left to right, then go to the beginning of the next row and work from left to right again, like reading a page. Carry on this way crossing out any P's and W's with one mark of the pencil like this. (Demonstrate). Carry on until I tell you to stop. Work as quickly and as accurately as you can. Nurse: Set your stopwatch for one minute. Tell the participant to start and stop at the correct moment.

I would now like you to do 10 chair rises. First I will ask you to fold your arms and, after I say, ‘And Go’, stand up from your chair and sit down again 10 times like this, as quickly as possible (demonstrate). Are you willing to do this test?

I would now like to assess your balance and co-ordination. First, I will ask you to fold your arms and, after I say ‘And Go’, stand on your dominant leg, and raise your other foot off the floor like this (demonstrate). I will ask you to hold this position for as long as you can or until I tell you to stop. Then I want you to repeat the test with your eyes closed. Are you willing to do this test?

Carry out test with participant's eyes open. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes open. Enter time in seconds as on stopwatch (to 1/100th second) Minutes ... Seconds

Carry out test with participant's eyes closed. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes closed Enter time in seconds as on stopwatch (to 1/100th second)

Now I would like to time you while you get up from the chair and walk at a pace that is normal for you to the furthest line on the floor, turn around, walk back and sit back in the chair. Are you willing to do this test?

Now I would like to assess the strength of your hand in a gripping action. After I say ‘And Go’ squeeze this handle as hard as you can, just for a couple of seconds and then let go. Are you willing to do this test?

Explain the procedure and demonstrate the test. Record the results of two blows by the participant in the boxes below. Record each blow as it is carried out. For each blow, enter measurements and code whether technique was satisfactory. If no reading obtained enter ‘0’and suppress all checks.

Nurse to complete lung function measurements on the participant feedback letter (use highest). Please tick the box to confirm you have done this:

1

Tick

M. DIET DIARY

The MRC National Survey team would like you to keep this diet diary for 5 days over the following week, including both Saturday and Sunday, and then send it back in this envelope as you last did in 1999 [delete if not applicable]. The participant did not complete the diary in 1999 [delete if not applicable]

Nurse to use instruction sheet from manual to remind participant how to fill out the diary and how to collect the food labels.

Nurse: Attach one HNR label on the inside front cover of diary and another on the plastic folder. Explain to participant that they return the diary and labels to MRC Human Nutrition Research in Cambridge in the envelope provided in the folder.

N. STEP TEST OR WALK TEST AND HABITUAL PHYSICAL ACTIVITY

The nurse must complete the medical review to ensure participant is eligible for the step test

Medical review

The answers to question 72a-f should be completed by the nurse, based on answers given previously or on the ECG trace. If any answer to 72a-f is ‘yes’ the step test will not be performed.

Did the participant: Report any of the following medical conditions at Q11 [aortic aneurysm, aortic stenosis, angina, myocardial infarction within last 3 months, myocarditis, cardiomyopathy, tachycardia, pulmonary or systemic embolism within the last 4 weeks] Please specify

Is there any reason you know of that means you should not follow an activity programme even if you wanted to? [if MI > 3 months ago check that participant has been approved for exercise by a physician] Please specify

Do you suffer from breathlessness that prevents you climbing one flight of stairs or walking unaided on the flat for less than 10 minutes? [include breathlessness due to chronic lung disorders or unspecified valve disorders]

The last physical activity I would like you to do is to step on and off this step for a few minutes in time to a beat which will start at a slow pace, then get a little faster. I will stop the test after 8 minutes, or earlier if you want to stop or your heart rate reaches a certain level. Are you willing to do this test?

This test is very simple. I want you to walk 250 metres (about 275 yards) at your own speed and keeping a regular, consistent pace over the entire distance. It is not the aim to get there in the shortest time. Are you willing to do this test?

We would like you to wear the actiheart monitor for the next 5 days while you carry out your normal activities. This would give information about your energy expenditure. The monitor is waterproof and does not need to be taken off when you bathe although you may remove it for short periods if you need to. You will be given instructions to take away with you and a box and pre-paid label for posting it back to us. If you want, we can send you information about your results.

“Here are the instructions for collecting these samples. We are asking you to collect one sample between 9.00-9.30p.m this evening, a second sample as soon as you wake up tomorrow morning, and a third sample 30 minutes after waking up. Each time you will need to write down on this form the actual time the sample was taken and report any stress, anxiety or trauma that occurred in the hour before the sample was taken. Then we would like you to place each salivette tube in to the transport container and place them in this pre-paid jiffy bag, and post the bag back to the lab. Thank you very much for taking the time to do this.” [If participant has a visit on a Friday, please ask them to take the first sample on Sunday night and the other two samples on Monday morning and then post them back to the lab]

Explain we need to obtain their consent to be interviewed and measured today and to use information collected today and at previous times for research. Explain that even having given consent they can still decline to do any part of the interview or examination.

Explain we will be asking them to consent to send results to their GP that may be useful for their health care and that this will be explained at the relevant parts of the examination. Confirm the GP address already on the GP letter. If the GP details have changed use a new GP letter. If the participant does not want any results sent to their GP use the participant feedback letter rather than the GP letter.

If the participant does not want results sent to GP, ask them to sign the clinical advisor consent form. Explain that if this consent is not given, a blood sample cannot be drawn and certain cardiovascular tests cannot be taken.

please give details in the table below. Use one row for each medication. Be sure to include use of puffer or inhaler or any medication for breathing, and any medications bought from a pharmacy.Use spare medication sheets if necessary and attach to questionaire

Has a doctor told you that you have any of the following health problems? Health Problem Other heart trouble (Valvular disease, Ischaemic heart disease, tachycardia, palpitations or heart murmur, other) Please specify

E. SELF-COMPLETION

“Now it’s time for breakfast and while I am getting that ready I’d like to give you this questionnaire to fill in by yourself. The questions are about how you have been feeling recently. Please check with me if any of the questions are unclear.”

J. SALIVARY CORTISOL

“We are collecting saliva to measure cortisol, one of the body’s hormones. Cortisol levels are related to many aspects of our health that we are measuring in this data collection. We would like you to unscrew the cap of this salivette tube and pop the swab in your mouth without touching it. We would like you to keep the swab in your mouth and roll it around your mouth for 1-2 minutes until you feel that you can longer prevent yourself from swallowing the saliva produced. Then we want you to spit the swab back into the small container and screw the top on.”

“Cortisol levels can change between morning and night and we would like you to take some more saliva samples at home and post them back to the clinic. I’ll explain more about this at the end of the visit.”

Which of the letters on the show card represents your total net household income? Please include our own and your partner’s earned income (after deduction for income tax and national insurance), any state benefits and any other sources of income such as pension and interest. Please also include contributions from other members of your household (such as children). Please choose the period (annual, monthly or weekly) that is most convenient for you to use. Then, find the amount in pounds which represents your net household income and state the corresponding letter. Letter

How frequently at home or at work do you use your hands in strong movements, such as squeezing water out of a towel, playing racket sports, digging the garden, or carrying heavy items such as a suitcase, briefcase, bucket or shopping bag?

Put your finger on this key marked ‘0’ and look at the screen. This is the only key you will need to use. Every time you see a ‘0’ or an ‘8’ on the screen press the key once as quickly as you can. We will start with a practice run to make sure you know what to do. Are you clear about it? I am going to start the machine now, so look for the ‘0’s or ‘8’s and press firmly as soon as you see one.

I’m now going to give you a slightly harder test. This time the numbers 1, 2, 3 or 4 will appear on the screen. I want you to press the key that has the same number as that on the screen. If you see a ‘4’ on the screen, press key 4 as quickly as possible. If you see a ‘1’, press key 1, and so on.

WORD LIST MEMORY

Now I want to see how well you remember a list of fifteen words. I will show you one word at a time and when I reach the end of the list you have one minute to write down as many words as you can. Please write the words in any order you like. It is best not to talk to anyone while you are doing this. Are you willing to do this test?

Nurse: Hand over the paper test booklet turn to page 3 and make sure the participant has a pencil. Show the words at two second intervals using Word List A or B as specified on contact sheet and on front page of booklet. Make sure the last word is shown for two seconds. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 5. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 7. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish.

Start at the top left and work along the row from left to right, then go to the beginning of the next row and work from left to right again, like reading a page. Carry on this way crossing out any P's and W's with one mark of the pencil like this. (Demonstrate). Carry on until I tell you to stop. Work as quickly and as accurately as you can. Nurse: Set your stopwatch for one minute. Tell the participant to start and stop at the correct moment.

CHAIR RISES

I would now like you to do 10 chair rises. First I will ask you to fold your arms and, after I say, ‘And Go’, stand up from your chair and sit down again 10 times like this, as quickly as possible (demonstrate). Are you willing to do this test?

BALANCE AND CO-ORDINATION

I would now like to assess your balance and co-ordination. First, I will ask you to fold your arms and, after I say ‘And Go’, stand on your dominant leg, and raise your other foot off the floor like this (demonstrate). I will ask you to hold this position for as long as you can or until I tell you to stop. Then I want you to repeat the test with your eyes closed. Are you willing to do this test?

Carry out test with participant's eyes open. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes open. Enter time in seconds as on stopwatch (to 1/100th second) Minutes ... Seconds

Carry out test with participant's eyes closed. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes closed Enter time in seconds as on stopwatch (to 1/100th second)

Minutes Seconds

TIMED GET UP AND GO

Now I would like to time you while you get up from the chair and walk at a pace that is normal for you to the furthest line on the floor, turn around, walk back and sit back in the chair. Are you willing to do this test?

HAND GRIP

Now I would like to assess the strength of your hand in a gripping action. After I say ‘And Go’ squeeze this handle as hard as you can, just for a couple of seconds and then let go. Are you willing to do this test?

Explain the procedure and demonstrate the test. Record the results of two blows by the participant in the boxes below. Record each blow as it is carried out. For each blow, enter measurements and code whether technique was satisfactory. If no reading obtained enter ‘0’and suppress all checks.